Robert B. Doherty; Ryan A. Crowley; for the Health and Public Policy Committee of the American College of Physicians*
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Current Author Addresses: Mr. Doherty and Mr. Crowley: 25 Massachusetts Avenue NW, Washington, DC 20001.
Author Contributions: Conception and design: R.B. Doherty, R.A. Crowley.
Analysis and interpretation of the data: R.B. Doherty, R.A. Crowley.
Drafting of the article: R.B. Doherty, R.A. Crowley.
Critical revision for important intellectual content: R.B. Doherty, R.A. Crowley.
Final approval of the article: R.B. Doherty.
Administrative, technical, or logistic support: R.B. Doherty, R.A. Crowley.
Collection and assembly of data: R.B. Doherty, R.A. Crowley.
The U.S. health care system is undergoing a shift from individual clinical practice toward team-based care. This move toward team-based care requires fresh thinking about clinical leadership and responsibilities to ensure that the unique skills of each clinician are used to provide the best care for the patient as the patient's needs dictate, while the team as a whole must work together to ensure that all aspects of a patient's care are coordinated for the benefit of the patient. In this position paper, the American College of Physicians offers principles, definitions, and examples to dissolve barriers that prevent movement toward dynamic clinical care teams. These principles offer a framework for an evolving, updated approach to health care delivery, providing policy guidance that can be useful to clinical teams in organizing the care processes and clinician responsibilities consistent with professionalism.
Members of health care teams often come from different backgrounds, with specific knowledge, skills and behaviors established by standards of practice within their respective disciplines. Additionally, the team and its members may be influenced by traditional, cultural, and organizational norms present in health care environments. For these reasons it is essential that team members develop a deep understanding of and respect for how discipline-specific roles and responsibilities can be maximized to support achievement of the team's shared goals. Attaining this level of understanding and respect depends upon successful cultivation of the personal values necessary for participating in team-based care.
The issue of team leadership has sometimes been contentious, especially when approached in the political or legal arenas, where questions about team leadership often become entangled in professional “scope of practice” issues ... . However, our interviews [with high-functioning teams] produced two potentially helpful observations. First, these questions seem much less problematic in the field than they are in the political arena. Among the teams we interviewed, notions of “independent practice” were not relevant because no one member of the team was seen as practicing alone, and leadership questions were not sources of conflict; rather, when leadership issues were raised they were portrayed as matters for open discussion that led to mutually agreeable solutions. Second, this relative lack of conflict might be because these teams use the term “leadership” in a nuanced way. There is widespread agreement that effective teams require a clear leader, and these teams recognize that leadership of a team in any particular task should be determined by the needs of the team and not by traditional hierarchy ... . (3)
NPs [nurse practitioners] are critical to improving access to health care in underserved communities. Most state laws do not include physical proximity requirements for supervising and collaborating physicians, allowing NPs to provide much-needed primary care in rural and other underserved communities. The success of health care delivery will require collaborative teams of physicians and nonphysicians to provide quality care for individuals and populations with both common and complex health care needs using evidence-based guidelines and effective models of collaboration. (8)
NMHCs are mostly independent nonprofit organizations or academically based clinics affiliated with schools of nursing. NMHCs provide primary health care, health promotion, and disease prevention services to people in rural and urban areas with limited access to health care and record over 2.5 million annual patient encounters. More than 250 NMHCs operate throughout the U.S. and serve an estimated 250,000 patients. The centers are managed by advanced practice nurses, and care is provided by NPs, collaborating physicians, clinical nurse specialists, RNs [registered nurses], health educators, community outreach workers, and health care students. As safety net providers, NMHCs supply cost-effective care that reduces expensive emergency room use and hospitalization among patients. (8)
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Dixie A. Jones, AHIP, Helen-Ann Brown Epstein, AHIP
Medical Library Association
December 4, 2013
On behalf of the 4,000 members of the Medical Library Association we are writing to express our support for Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians (ACP) Position Paper, and to encourage ACP to specifically mention health sciences librarians as members of the clinical care team. Research demonstrates that the information that health sciences librarians provide has value and makes a positive impact on patient care (1, 2).
Health sciences librarians have a long history as members of the health care team, serving as clinical medical librarians, and more recently as clinical informationists. A recent study shows that more than seventy percent of health practitioners have reported handling some aspect of patient care differently as a result of the information obtained from the library and information resources, and that the information resulted in their making more informed clinical decisions, avoiding or reducing the possibility of adverse events, and having a positive impact on patient care (1, 2). Evidence also shows that when clinical medical librarians participate in patient rounds and morning report, health professionals obtain answers to clinical questions more quickly and efficiently, and treatment plans are changed based on both the evidence-based information that librarians provide, and after learning new information skills taught by librarians. (3)
Clinical informationists, highly trained knowledge management health sciences librarians with informatics expertise, have demonstrated their value and effectiveness for integrating best evidence into patient care, thus making them crucial members of the health care team. (4)
Professional health sciences librarians can further the American College of Physicians’ goal to support team-based care, particularly as noted in Principle 1. under “Research and Measurement Related to Clinical Care Teams,” that states that “Optimal formulation, functioning, and coordination in team-based care to achieve the best outcomes for patients should be evidence-based.” We respectfully urge ACP to mention health sciences librarians as members of the clinical care team.
Dixie A. Jones, AHIP Helen-Ann Brown Epstein, AHIP
President, Medical Library Association Chair, MLA Hospital Libraries Section
1. Sollenberger, JF, Holloway, RG. The evolving role and value of libraries and librarians in health care. JAMA, 2013: 310 (12): 1231-1232.
2. Marshall JG, Sollenberger JS, Easterby-Gannett S, et al. The value of library and information services in patient care: results of a multisite study. J Med Lib Assoc. 2013:101(1):38-46.
3. Aitken EM, Powelson SE, Reaume RD, Ghali WA. Involving clinical librarians at the point of care: results of a controlled intervention. Acad Med. 2011:86(12):1508-1512.
4. Guise NB, Williams AM, Giuse DA. Integrating best evidence into patient care: a process facilitated by a seamless integration with informatics tools. J Med Lib Assoc. 2010:98(3):220-222.
Doherty RB, Crowley RA, for the Health and Public Policy Committee of the American College of Physicians*. Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper. Ann Intern Med. ;159:620–626. doi: 10.7326/0003-4819-159-9-201311050-00710
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Published: Ann Intern Med. 2013;159(9):620-626.
Ethics, Healthcare Delivery and Policy, High Value Care.
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